In this post, we will take a deep dive on Medicaid rules for peer support services in California, Texas, Florida, New York, and Pennsylvania. Including answers to questions like:
Are peer support services covered under Medicaid in California, Texas, Florida, New York, and Pennsylvania?
What copays are required, if any, for peer support services in these states?
What limitations and exclusions exist for peer support services in these states?
What else should sober living home entrepreneurs and operators know about Medicaid rules and regulations on peer support services in these popular states?
What Kinds of Sober Living Homes Generally Offer Peer Support Services? Are Peer Support Services Right for your Recovery Residence?
According to SAMHSA’s Best Practices for Recovery Housing, it’s very common for sober living homes and recovery residences to add peer support services to their programming. Although not all sober living environments do this, it can be a lucrative add-on for operators, as well as a meaningful and supportive service for residences. In fact, peer support services are an evidence-based service for people in early recovery and are increasingly considered to be an indispensable part of the continuum of care.
The National Association of Recovery Residences, or NARR, recognizes four distinct levels of sober living environments. It’s typical for levels three and four to incorporate peer support services.
In Level 3 homes, it’s common to find a paid house manager, an administrative support assistant, as well as a certified peer recovery support service provider who meets with residents regularly.
In Level 4 homes, it’s generally expected that peer recovery support specialists will be offered as an on-site service.
What is the CPT Billing Code for Peer Support Services in California, Texas, Florida, New York, and Pennsylvania Sober Living Homes?
Peer support services are typically billed using the CPT code, H0038. When those services are provided within the context of an addiction treatment program, the modifier “HF” can be tacked on to the end. Some sober living homes are technically addiction treatment programs, but many are not. If your sober living home does not provide addiction treatment, then you’ll want to omit the “HF” modifier.
In some cases, other modifiers may be relevant, such as the “HQ” modifier, which describes services provided in a group setting. An educational group session conducted by a peer recovery specialist is a good example of an occasion where the “HQ” modifier may be appropriate.
If the peer support professional provides services via telehealth, an increasingly popular and practical option, then the “GT” modifier may be used.
How Can I Find Out if Other States Cover Peer Support Services Under Their Medicaid Programs?
KFF’s Medicaid Behavioral Health Services: Peer Support Services is a one-stop shop that keeps an updated list of all state policies regarding peer support service Medicaid coverage. The list includes the following information: specific services covered, any limits on those services, and what copays (if any) are required to access those services.
Are Behavioral Health Peer Support Services Covered in California, Texas, Florida, New York, and Pennsylvania?
Yes. Here’s the state-by-state breakdown:
California Peer Support Services Coverage: Both mental health and behavioral health peer support services are covered without limitation for Medical patients. There are no copay requirements.
Texas Peer Support Services Coverage: Peer support services are covered in Texas and there is no copay to access these services for Medicaid patients. There is one limitation, however. Only 104 units (15 minutes per unit) may be billed within any one 6 month period, unless a documented medical necessity exists for additional units.
Florida Peer Support Services Coverage: Florida Medicaid covers peer support services without requiring any copay. However, only one 15-minute unit of service may be accessed for every day within a calendar year.
New York Peer Support Services Coverage: Like California, New York Medicaid covers peer support services without a copay and without limitation.
Pennsylvania Peer Support Services Coverage: Pennsylvania Medicaid covers peer support services and there are no limitations to service. Managed care patients in Pennsylvania are not required to cover a co-pay. All other Medicaid patients owe a co-pay of $0.65 for every 15-minute unit of service they access.
More Blog Posts About California, Texas, Florida, New York, and Pennsylvania Sober Living Home Business Development
How to Open a Sober Living Home in California
How to Open a Sober Living Home Business in Pennsylvania
Considering Opening a Sober Living Home in Florida? Here's How.
How to Open a Sober Living Home in New York
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